P - 75143Minnesota Department of Labor and Industry
443 Lafayette Road North
St. Paul, MN 55155�342
Phone: (651) 284-5064
TlY/MRS: (651) 297�1198
www.electricity.state.mn. us
Homeowner
Rough-In Inspection Required?
5/2/08 � Homeowner
Address of InspecUon - Street
124 GLEN CREEK ROAD
Owner Name
KURT BECKER
Owner Telephone Number(s) - I
(763) 574-7228
Owner Mailing Address - Street
124 GLEN CREEK ROAD
uest for Electrical Ins ection
] Yes Inspection Other Than Rough-In:
Ins ctions Homeowner Must Schedule All Final Ins c
City/Township County
FRIDLEY ANOKA
REPLACE ELECTRICAL BOX
City
FRIDLEY
Electrical Utility
Ready Now
Will Schedule
State Zip Code
MN 55432
thepucksmith@hotmail.com I
By signing this document, I certify that I am the owner as defined by Minn. Stat. § 326.01 and will legally perform the electrical work
Owner Signature
Fee Calculation
New Home or Associated Structure Existing Home/Structur emodel or Addition
New Home Service/Power Supply 0— 400 ampere @$35 $0 New Service/Power Su ly. �°'`� 0— 400 ampe $35 $35
�
New Home Service/Power Supply 401 — 800 ampere @$60 New Service/Power Supply 401 — S00 ampere @$60
New Home Feeders/Circuits New/Extended Feeders/Circuits — Up to 15 Feeders/Circuits
U to 30 Feeders/Circuits -$100 Feeders/Circuits $6 Each or 16 to 30 $100
New Home — More than 30 Feeders/Circuits (in addition to New/Extended Feeders/Circuits — More Than 30 Feeders/Circuits
above FeederslCircuits U To 200 A $6 Each Feeders/Circuits U to 200 A $6 Each
Other (Specify) Reconnected Feeders/Circuits
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
( 2 �) Feeders/Cirouits $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Soeciiv)
TOtal (the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 multiplied
by the number of required inspection trips, by the number of required inspection trips,
whichever is greater) whichever is greater) $35
Requ�ffi for Electrlcal InspecUon (REI) wlth a fee of $250 or less explre 12 montF�s from the flling date. The owner must have the work completed wfthtn
12 month peHod or submk another REI that Includes the Inspectlon fee for the uncompleted work InspecUon fees do not carry over from one REI to an er.
A servlce cha e of $30 wlll be added for all dlshonored checks.
I hereby certify that I inspected the electripl installaHon herein on the dates stated: ��or D�epartrnen�se Only ����
Rough — In Inspection(s) Date i� _.,/ V� ( �
u �, •�
Thls m�,¢f rlaTcan be
TDD (657) 297�198.
REI 01 (6/0�
a �
Date �� �AY 0 8 2008
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as large print, Brallle or on a tape. To request, call 1-800-3
or